Provider Demographics
NPI:1528024833
Name:ROBERTS, MARK DAVID (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 PAMLICO RUN
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23693-2711
Mailing Address - Country:US
Mailing Address - Phone:757-503-5524
Mailing Address - Fax:
Practice Address - Street 1:149 HART ST
Practice Address - Street 2:82D MEDICAL GROUP/MARK D ROBERTS, CAPT, USAF, DC
Practice Address - City:SHEPPARD AFB
Practice Address - State:TX
Practice Address - Zip Code:76311-3482
Practice Address - Country:US
Practice Address - Phone:940-676-4474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC71721223E0200X
LA55401223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD 000Medicare UPIN